Asked about his interest in better medical record-keeping, Devore Culver tells a brief but vivid story. He was a young unit coordinator – part secretary, part head nurse – at Mass General when, he said, “I participated in killing a patient.”
“Everything was on paper, and there was a lot of bad information,” Culver said of the records. One day, he was talking with a nurse who carried out a physician’s order to give a diabetic patient 40 units of insulin. Not long after, an intern stopped by and told them he had already given 40 units to the patient – who died of an overdose.
“There had to be a better way,” Culver said. And he has devoted most of his subsequent career to that goal.
Since 2004 he has tackled the electronic medical records (or EMR) problem, first at Eastern Maine Medical Center in Bangor, and now with Maine HealthInfoNet, a nonprofit, state information exchange. Despite recent funding from federal sources, creating a coordinated network of digitized medical records has been daunting and progress slow. Expectations that the network would be operating and producing more coordinated care and, perhaps, lower health care costs, haven’t as yet materialized.
It turns out that the problem is nowhere as simple as transferring paper records to computers. The whole nature of health care “data” is radically different from what we normally expect computers to do, said Culver.
“This is not like banking, where you can quantify everything that’s important,” Culver said. Reducing an individual’s health care history, and prospects, to numbers isn’t easy, and there is so far little agreement even on such seemingly simple points as how to define the “normal” ranges on various medical tests.
The amount of data available, Culver said, is overwhelming. HealthInfoNet can, “every night, run information for 1.5 million people.” Yet sorting, defining and translating data into terms that can benefit providers and their patients is still very much a work in progress.
Andrew Coburn, professor of public health at the University of Southern Maine’s Muskie School, has been observing health care reform since before the Clinton Health Care Taskforce in 1993. EMR systems have required providers to spend more time entering data, which may reduce “face time” with patients. Yet he said electronic records offer so many potential benefits “there’s no going back” now.
Coburn said there can be “huge safety and quality benefits” from creating records that “capture the nuance of clinical information.” And, he said, “When a patient can go to an ER after being treated in a separately owned cancer facility, that’s a really important clinical benefit.” Yet attaining those results in a health care system that still involves thousands of separately owned providers, is likely to be elusive for some time to come.
THE DIGITAL PUSH
The notion that medical records should be digitized so they can be shared easily among a person’s health care providers was part of the American Recovery and Reinvestment Act of 2009, the “stimulus bill” that followed the nation’s financial crash a year earlier. The initiative was further refined by the Affordable Care Act in 2010.
Proponents argued that easy, but protected, access would allow for more informed, coordinated care, more engagement with patients and their families, and prevent redundant testing or dosing such as the one that doomed the patient at Mass General. The federal government mandated that health care providers should demonstrate “meaningful use” of EMR by Jan. 1, 2014. Those who didn’t by 2015 could be penalized with a 1 percent reduction in Medicare reimbursements.
The ARRA provided $19.2 billion for improving health care technology, a significant portion of which went to EMR systems – by far the largest federal commitment to date. All 50 states received money, including Maine, which received $6.6 million.
Culver said that the billions of dollars provided to states under the ARRA were a mixed blessing. The fundamental problem, he believes, was that the software programs that quickly went into use were being sold by experts in technology who knew little about health care, to health care experts who knew little about technology. Yet the grants did lay down a foundation for eventual improvement, he added.
And there have been success stories. Culver helped St. Joseph’s Hospital in Bangor reduce its readmission rate by 13 percent through better tracking of which patients would need additional support after being discharged.
In the 10 years Maine HealthInfoNet has been up and running, it has focused on “making data more meaningful,” Culver said – a key point since, as it turns out, doctors don’t even have a standard terminology for identifying something as simple as the sound of a patient’s cough. At this point, he said, along with Maine, only Delaware and Nebraska, and to an extent Rhode Island, have created statewide systems that meet this “value added” standard set by the federal government.
EFFICIENCY AND WORKFLOW
Dan Mingle understands the complexities of EMR. A family physician who practiced for 14 years in Norway, he grew frustrated by what he saw as the disconnected nature of his profession. Since middle school, “I had always had an aptitude for electronics,” he said, even buying one of the first Tandy computers. But his interest had been dormant until he moved to the Maine-Dartmouth Family Medicine Residency, a teaching institution that’s part of MaineGeneral in Augusta.
Maine-Dartmouth needed better electronic tools for residents, and Mingle was soon working full time on the project, eventually become chief information officer for the entire hospital.
He was able to set up medical reporting forms that could be used by all the providers in the regional hospital’s area, and the results were a major advance toward the aim of producing instantly available, standardized records that could be used by emergency room doctors and everyone else who might be treating the patient. Yet scaling up such advances to the state, regional and national levels has been daunting.
Mingle founded Mingle Analytics in 2011 in South Paris, which now has 58 employees and contracts with providers, from solo practitioners to systems with thousands of employees, in all 50 states. The company is trying to bridge the gaps between the original federal initiative and the day-to-day issues each provider faces in keeping track of patients, billing insurance companies, and trying to guide people toward better health, rather than just treating illness.
Mingle said he recommends three strategies to create a path toward successful EMR implementation: “Standardize, integrate – make sure everything works together,” and “simplify – look for ways to cut out steps.” Too much initial EMR work, in his view, tried to adapt electronic systems to existing patterns rather than figuring out how to create efficient work flows.
“Engrave them on your boardroom wall,” Mingle said of the three points. “If your policy doesn’t follow one of these rules, it’s probably not the right decision.” q
This story was changed from its original version to correct the length of time HealthInfoNet has existed, and to correct the readmission rate at St. Joseph’s Hospital.